Failure to Prevent Neglect and Respond to Opioid Overdose
Penalty
Summary
A facility failed to protect a resident from neglect, resulting in the administration of four incorrect doses of morphine sulfate totaling 80 milligrams over a 12-hour period. The resident, who was admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home. The error originated from a transcription mistake during the medication reconciliation process, where three out of five morphine orders were entered incorrectly and the facility's triple check system was not fully completed, lacking a third verification signature. The error was discovered only after a nurse questioned the order, at which point the incorrect order was discontinued and a corrected order was entered. Following the medication error, the resident became lethargic and unresponsive, with unstable vital signs including low blood pressure and oxygen saturation. Despite these changes, there was no documented evidence that the facility provided interventions to reverse the effects of the opioid overdose, such as administering naloxone (Narcan), even after the family inquired about it. Additionally, there was a lack of documented monitoring, assessment, or treatment for the resident's decline after the error was identified. Vital signs and nursing assessments were not consistently recorded, and there was no evidence of physician oversight or coordination with hospice regarding the medication error. Communication failures further contributed to the deficiency. The resident's representative was not notified of the medication error until after the resident's condition had significantly deteriorated. Hospice was not informed of the medication error, and attempts to contact hospice during the resident's decline were unsuccessful due to incorrect contact information. Key facility leadership, including the Director of Nursing and Administrator, were not promptly informed of the incident, and staff interviews revealed a lack of awareness and documentation regarding the resident's condition and the actions taken. The resident ultimately expired without documented evidence of appropriate monitoring or intervention following the overdose.
Removal Plan
- Post Hospice contact information in each nursing unit and include on the face sheet for residents actively on Hospice.
- Make the contact for Community Hospice visible at accessible locations such as a nursing station on each resident unit.
- Ensure that for all residents enrolled in Hospice services, the contact number for Community Hospice is visible and accessible under contacts on the residents' face sheets in both electronic and paper charts.
- Update medication error reporting policy to require the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring, and expected follow up communication.
- Require documentation of the nature of the incident, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments, and communication.
- In-service all on-call Physicians and Nurse Practitioners regarding high-risk medications and review of electronic ordering for safe dosing.
- Educate all nursing staff, including agency staff, by the nursing educator/designee on the updated Medication Error Reporting policy, including directions on provider and family notification as well as resident monitoring and documentation requirements.
- Use education sign-in sheets to document that in-house and agency nurses were educated; educate remaining agency nurses if they return to the facility.
- Compare transcribed orders with original provider order for accuracy; complete and document checks in the paper chart for the next two consecutive shifts.
- Educate all nursing staff (including agency staff) by the nurse educator, supervision, or designee regarding medication reconciliation, medication transcription, triple check, and safe medication administration practices.
- In-service all in-house and agency nurses regarding the abuse/neglect and mistreatment policy, with a special focus on potential neglect related to medication errors and lack of monitoring, assessment, and documentation related to change in condition.